PLASTIC SURGERIES

From Big Medical Encyclopedia

PLASTIC SURGERIES (grech, plastike sculpture, plastics) — operative measures which key feature is movement (transplantation, change) fabrics and bodies or implantation of the materials replacing them. Items of the lake are the main method plastic surgery (see) which combines methods of a surgical reconstruction of an integrity of members of the body and recovery of their function at the inborn or acquired defects.

History

lakes were used by P. in Ancient India and Ancient Egypt. In the beginning most intensively the skin plastics developed. So, the Indian surgeons recovered Nov by movement of the rag on a leg found from skin of a forehead (the Indian method). In Italy for this purpose began to use the skin rag on a leg formed on a shoulder (the Italian method). In the subsequent the skin plastics gained considerable development. The big contribution to development of this problem was made, in particular, by Yu. K. Szymanowski, A.S. Itsenko, S. M. Yanovich-Chaynsky, V. K. Krasovitov, A. A. Limberg, V. P. Filatov, Yu. Yu. Dzhanelidze, Zh. Reverden, Tirsh (To. Thiersch), etc.

Free change of bones was applied in 17 — 18 centuries. A founder of not free change of a bone is N. I. Pirogov. The big contribution to a problem of bone plastics was made A. A. Nemilov, by H. N. Petrov, N. A. Bogoraz, P. G. Kornev, Ollye (L. X. E. Oilier), E. Lekser, etc.

In practice of modern surgery in connection with development of medicobiological sciences (hematology, genetics, immunology, a cryobiology, etc.), improvement of the surgical equipment, implementation of methods microsurgery (see) the range of use of P. of the lake considerably extended. Change not only various fabrics, but also the whole bodies became possible.

Classification

At P. islands use own tissues of the patient (see. Autoplasty ) or the allogenic fabrics taken from other person — the donor (see. Homoplasty ), the xenogenic fabrics taken from an animal (see. Heteroplasty, xenoplasty ), alien not biological materials — metal, synthetic substances, etc. Autogenic fabrics can change completely separated from a maternal basis (free change) or at preservation of the feeding leg (not free change). Other plastic materials change only by methods of free plastics.

Free change is applicable at all types of plastics. The autoplasty at which the fabric replaced with observance of all necessary conditions usually well begets is most effective, without causing side reactions. If the begot fabrics receive further a functional load inherent to them, then they keep the form, structure and function. At other types of plastics biotransplants carry out replaceable (sometimes stimulating) a role only temporarily and in the subsequent collapse body tissues. The alien materials applied at explantation are encapsulated and a long time can carry out a mechanical role of a prosthesis.

Change of autogenic fabrics is applied at P. by the lake on many fabrics and bodies.

Fig. 1. The patient with a scalped wound of the head: and — before operation; — after skin plastics by a method of stamps.

Most often skin changes (see. Skin plastics ), when it is necessary to close the fresh or granulating wound. By means of a knife, the razor or special tools (dermatoma) skin rags of various sizes and thickness undertake. At rather small defects free skin transplants it is possible to close a wound entirely. At operational treatment of deep burns and extensive defects of skin of other etiology often apply the so-called economical methods allowing to close wounds the minimum quantity of skin. At the same time mesh rags — the small rags placed on nek-rum distance one from another (a method of stamps, fig. 1, and, b), etc. are used. A kind of free autotransplantation of skin is use offered by V. K. Krasovitov (1935) torn away at an injury from a maternal bed of a rag which after disinfecting and removal of hypodermic cellulose is returned to previously debrided wound.

Change of a bone tissue is widely applied at P. by the lake in orthopedics and traumatology (see. Bone plastics ). For the plastic purposes transplants from compact and spongy substance of bones are used. At bone plastics transplants perform three important functions: mechanical (fixing of fragments), biological (stimulation of bone formation) and replaceable (completion of defects). According to most of surgeons, change of autogenic bones gives more than 95% of favorable outcomes.

Change of cartilaginous tissue won universal recognition and was widely adopted. The cartilage is easily processed by a knife, it is elastic, steady against an infection and disturbances of blood supply. According to T. P. Vinogradova, transplants of a cartilage for many years do not collapse, keeping an initial form and the sizes. The transplants prepared from costal cartilages are replaced or in the form of monolithic pieces, or in the crushed look. Change of a cartilage is made more often at cosmetic face operations (for a raising of a ridge of the nose, formation of auricles, etc.).

Change of sinews is applied to substitution of defects of the sinews arising at injuries and various diseases. Transplants take from the sinews which are near defeat. Freely replaced autogenic sinews well beget as process of a metabolism at them proceeds not intensively. Function of tendinous transplants with firmness remains.

Change of a fascia and aponeuroses is usually used for substitution of fascial and aponeurotic defects, napr, at ventral hernias, and also for recovery of the broken-off sinews and the copular device. The fascia well begets, with firmness keeps the structure.

Change of muscles is applied for the purpose of sealing of bone cavities (e.g., at osteomyelitis) and tamponades of parenchymatous bodies (a liver, kidneys) to a stop of bleeding. The replaced muscles which lost the function rezorbirutsya and replaced with connecting fabric.

Change of vessels made the defined progress lately. Use the autogenic veins taken on a hip more often. Replace with such transplants defects of arteries, and also their sites affected with atherosclerosis. Venous transplants are not thrombosed, their wall under the influence of supertension is reconstructed, approaching on a structure an artery. Occasionally for plastics of vessels use also autogenic arteries which removal is not followed by disturbances of blood supply (see. Arterialization of a myocardium , Atherosclerosis, surgical treatment , Blood vessels, operations ).

Change of nervous trunks is made more often at substitution of the traumatic defects which are followed by disturbance of motive function. The damaged motor nerve is usually sewed at roughing-out of a wound or it is delayed (see. Nervous seam ). If it is not possible to pull together the ends of the injured nerve, then it is replaced with a piece of a sensory nerve. The transplant serves as if as the conductor (case) on which there is a regeneration of fibers of the injured nerve.

Change of allogenic fabrics and bodies. The autoplasty can not always meet requirements of plastic surgery to quantity of transplants, their sizes and a form. At preparation of autografts to the patient the additional injury is done. All this forced surgeons to resort to use of the fabrics and bodies received from healthy donors or from corpses of the people who suddenly died from various damages. The alloplasty is quite often combined with an autoplasty (e.g., a cartilage and skin; bone and fascia). At an alloplasty the particularly important becomes the organization of so-called fabric banks in which biological material is stored in a tinned look.

Engraftment of allogenic fabrics and bodies depends not only on the operational equipment. The result of such changes first of all is defined by reactions of transplant immunity (see. Immunity transplant , Incompatibility immunological ). Expressiveness of these reactions and process of engraftment of the allogenic transplants taken from various fabrics are not identical. On gistogenotichesky, functional, plastic and immunological signs all allogenic materials used at P. by the lake divide into five groups.

Carry skin and a cornea to the first group. Allogenic skin has the greatest antigenic activity. It begets only for 2 — 3 weeks, and then there comes reaction of rejection. Therefore the alloplasty of skin is used only for temporary closure of extensive wounds, it is almost exclusive after deep burns.

The cornea has weak antigenicity, at its change good results are achieved. Total and partial keratoplasty (see) provides recovery of sight.

Include bones, cartilages, sinews, a fascia and an aponeurosis in the second group. They are poorly antigens; after change are exposed to destruction with the subsequent substitution by own fabrics. At their transplantation the good result is usually achieved. E.g., allotransplantation of bones at nearthroses yields more than 80% of positive takes. Change of allogenic cartilages is almost also productive as well as autogenic, in an organism of the recipient they a long time do not collapse, with firmness keeping an initial form and the sizes. Allotendoplastika is widely used at elimination of defects of sinews after injuries. The allogenic fascia on outcomes of plastics does not concede autogennsh to transplants.

Blood vessels enter into the third group, to-rye are used for recovery of the broken blood circulation. Replace the slaboantigenny lyophilized arteries, to-rye in an organism of the recipient are gradually replaced with tissue of the patient.

The fourth group included the pleura, a peritoneum, a pericardium and a firm meninx having the expressed plasticity and weak antigenicity. The firm cover of a brain and a pericardium are applied at plastics of defects of a diaphragm, abdominal wall, etc.

The fifth group is made by fabrics of hemopoietic system at which change difficulties of overcoming a barrier of incompatibility are very big because of their high antigenic activity.

Fig. 2. Change of the allogenic distal end of a humeral bone after an oncotomy: and — the patient with an extensive osteoblastoclastoma of the distal end of the left humeral bone; — the roentgenogram of the affected humeral bone; in — a straight line and - side the roentgenograms of a humeral bone made right after plastic surgery (a proximal half of a humeral bone is replaced with allotransplant which is strengthened by the fixing design); d — a straight line and e — side roentgenograms of a humeral bone in 16 years after allotransplantation (full consolidation and the kept structures of a transplant are visible).

Organ transplantation (see. Transplantation ) became evidence-based only from the second half of 20 century with the advent of effective methods of overcoming a barrier of a tissue incompatibility. Selection (methods of fabric typing) of donors and recipients taking into account their histocompatability, and also suppression of reaction of rejection by immunosuppressors, in particular, concerns to them. Experimentally, and also the possibility of engraftment and long functioning of allogenic kidneys, heart and liver is clinically proved (see. Liver transplantation , Renal transplantation , Heart transplantation ). Change of allogenic joints is developed. V. G. Vanstein, A.S. Imamaliyev, etc. carried out change of knee and coxofemoral joints, P. P. Kovalenko — change of the distal end of a humeral bone after an oncotomy (fig. 2). Long-term overseeing by such patients show that the structure and satisfactory function of transplants with firmness remain.

Change of xenogenic fabrics of serious clinical value has no. Xenogenic fabrics have the expressed antigenicity and at transplantation either are torn away, or encapsulated. Some distribution was gained only by change of pigskin on the extensive wounds which are formed after deep burns. This method to a certain extent competes with allodermoplastiky.

Change of not biological materials — metal, organic glass, synthetic fabrics (explantation) was widely adopted at P. of the lake. From them prepare various prostheses (e.g., vessels, a crystalline lens) and devices (e.g., a joint of Sivash), artificial valves of heart, etc. are created.

Not free change is possible only at an autoplasty. The philosophy of not free plastics is movement of a transplant with preservation of feed vessels, i.e. on the so-called feeding leg. Respect for this principle allows to move full-layer rags of skin together with hypodermic cellulose or sites of bodies that gives the chance to make difficult reconstruction of bodies at their various defects.

The simplest method of not free skin plastics is mobilization and tightening of edges of a wound after drawing relief incisions. A. A. Limberg offered the technique of cutting out of counter triangular skin rags based on mathematical calculation of size of defect and a reserve of surrounding fabrics around it. This method is especially effective at cicatricial contractures of large joints, cicatricial deformations of the person (see. Skin plastics ).

At a lack of fabrics around a wound skin rags on a leg move from the remote sites (the Italian plastics). Important stage in development of this method of skin plastics was V. P. Filatov's proposal to form a pedicle graft. It with success is applied not only to plastics of trophic ulcers, not healing stumps, defects of a throat and a gullet, but also to recovery of various bodies: nose, lips, cheek, penis.

Also not free plastics of bones (e.g., osteoplastic amputation of foot across Pirogov), muscles (e.g., filling with a muscular rag on a leg of bone cavities, bronchial fistulas), sinews, etc. is applied. Not free change of muscles and sinews gives the chance to achieve the most reasonable distribution of the functioning fabrics. So, at Coffman's operation (movement of sinews of a back tibial muscle of an internal anklebone) function paralyzed razgibately foot is compensated.

Scope of plastic surgeries with use of various methods of change is very extensive.

Fig. 3. Recovery of phalanxes of a finger of a brush by not free change of phalanxes of a finger from foot: and — the patient before operation <sotsutstvut two phalanxes of the II finger of the left brush); — the first stage of plastic surgery (the end of a stump of the II finger of the left brush is hemmed to the III finger of the left foot); in — the same sick after operation.

In traumatology and orthopedics islands on bones, muscles, sinews, fastion for correction of traumatic defects widely resort to P., and also at sluggish and spastic paralyzes, etc. (see. Bone plastics , Horse foot , Paralyses, paresis , Poliomyelitis , Nearthrosis ). Items of the lake on joints are carried out by hl. in the way for the purpose of recovery of their mobility (see. Joints , Arthroplasty , Arthrorisis , Artrotenodez ). At sluggish paralyzes of the lower extremities undertake the stabilizing operations (see. Artificial ankylosis ), to-rye combine with change of sinews; at the same time considerable improvement of functions of extremities is quite often reached. Combined by P. the island it is possible to recover phalanxes of fingers, to make not free change of fingers from foot on a brush (fig. 3).

Plastic surgeries on a backbone and edges are shown at inborn uglinesses (spinal hernias, failure of union of handles of vertebrae) and the acquired deformations (a costal hump, a kyphosis, scoliosis, a spondylolisthesis, etc.). The problem of plastics includes recovery of a statics and function backbone (see).

Plastic surgeries on vessels and heart gained considerable distribution. They are shown for recovery of blood circulation in heart and other bodies (see. Arterialization of a myocardium , Shunting of blood vessels ) at the inborn and acquired defects. Various operations, since an arteriotomy and removals of blood clots before substitution of an aortic arch during the narrowings and aneurisms are carried out. Thanks to use of mikroangiokhirurgichesky methods change of fabrics on feed vessels with recovery of their blood circulation by means of a vascular seam gained distribution. So, replantation of fingers and a brush became possible (see. Microsurgery ).

Plastic surgeries on a gullet, a stomach and intestines make for the purpose of recovery of these bodies more often what usually apply intestinal transplants to. So, at cicatricial strictures of a gullet, after an esophagectomy concerning a tumor its recovery from a large or small bowel widely practices (see. Gullet artificial ); the intestinal plastics is applied at reconstructive operations for diseases of the operated stomach, and also at other dysfunctions of the food channel.

Plastic surgeries on respiratory tracts consist in a partial or circular resection or plastics of bronchial tubes and tracheas, and also closing of bronchial fistula (see. Bronchial tubes, operations , Bronchial fistula , Trachea ).

In neurosurgery of the Deputy are undertaken at inborn uglinesses (craniocereberal hernias), posttraumatic and postoperative bone defects, defects of a firm cover of a head and spinal cord, defects of nervous trunks, etc. (see. Brain , Cranioplasty , Nervous seam , Facial nerve ). At paralyzes of muscles operation operations of Shpittsi are made — the healthy motor nerve taken in the neighbourhood is implanted into the paralyzed muscle.

In P.'s ophthalmology of the lake carry out for the purpose of correction of defects of a century, a corner of an eye and a keratoplasty (see. Blepharoplasty , Canthoplasty , Keratoplasty ). Implementation of microsurgical methods allowed to expand indications to P. with the lake on organs of sight and to considerably improve their outcomes. Gained P.'s distribution by the lake, recovering passability of the lacrimal ways, eliminating amotio of a retina (see) and squint (see), operations on to an iris (see), keratoprotezirovaniye (see).

In P.'s otorhinolaryngology islands undertake for correction of deformation or recovery of a nose (see. Rhinoplasty ), recovery of a throat (see. Laryngoplasty ), at paralyzes of phonatory bands, esophageal and guttural fistulas. Make also P. the lake on sound conduction paths of an ear (see. Otoplasty , Tympanoplasty , Myringoplasty ).

In stomatology by means of P. defects of language, jaws, a chin, cheeks, and also an oral cavity and lips are eliminated with the lake (see. Lips , Person , Jaws ). The problem of operations includes elimination of functional and cosmetic shortcomings.

In urological practice of P. of the lake are undertaken for elimination of inborn and posttraumatic defects of urinogenital bodies, at the sclerosed or atonichiy bladder, extensive strictures of ureters and urethras, absence or uglinesses of a penis.

So, at an ectopia of a bladder and uglinesses of a penis step-by-step recovery of bodies is made. In the beginning replace ureters in an ampoule of a rectum or in an intestinal transplant, and then recover a penis by Bogoraz's method a bucket-handle graft with the cartilaginous trasplantat included in it (see. Intestinal plastics , Phalloplasty ).

In P.'s gynecology of the lake are effective on a uterus, a vagina, external genitals and a crotch (see. Prolapse of the uterus, vaginas , Colpopoiesis , Urinogenital fistulas , Crotch ). For substitution of defects local fabrics and intestinal transplants are used.

Cosmetic operations carry out for the purpose of elimination of the cosmetic defects which are quite often combined with dysfunction of body. They differ in a variety and specifics! operating. During the definition of indications to these operations consider importance not only medical, but also social and psychological rehabilitation as the people having cosmetic defects often consider themselves defective, become closed, aim at a privacy, difficult join work and public life.

Fig. 4. A type of the patient with deformation of a nose: and — before operation — after operation.
Fig. 5. Recovery of the destroyed nose and an ear: and — the patient before operation; — a stage of plastic surgery (the free end of a bucket-handle graft is replaced to a root of a nose); in — sick after operation with recovered by a nose and the left auricle.
Rice 6. Recovery of an auricle by means of an autoplasty of the skin taken in zaushno-occipital area and an allogenic cartilage: and - the patient with inborn defect of the right auricle before operation; — the flow diagram (across Kovalenko): allogenic hoyashch, shaped an auricle (it is shown at the left), it is entered through a section of skin (1) into the zaushno-occipital area (2), 3 a defective auricle; in — the begot transplant konturirutsya under skin (it is specified by an arrow); the same patient in 4 years after operation.

Cosmetic operations are more often made on person (see). By means of them reach decrease (fig. 4) or a raising of level of a ridge of the nose, recovery of wings of a nose, a complete recovery of the destroyed nose by means of a bucket-handle graft and change of a cartilage (fig. 5). Items of the lake are undertaken for correction of the sticking-out, wide and big auricles, and also for total recovery of an auricle, in particular from skin of zaushnozatylochny area and an allogenic cartilage (fig. 6). With the item of the lake on lips, eliminating the inborn and acquired uglinesses, liquidate also functional frustration (hypersalivation, etc.). Cosmetic operations at defects of a chin, cheeks, a century, a forehead, in particular are widely applied to elimination of prematurely formed wrinkles, an otvisaniye a century, cheeks.

On mammary glands cosmetic P. lakes are carried out at a polymastia, an amastia, an aplasia, a polythelia, some forms of a hypertrophy (see. Mammary gland, operations ).

On other areas of a body by means of cosmetic operations eliminate a tattoo, the posttraumatic and postoperative disfiguring hems, skin and fatty folds on a stomach, etc.

At cosmetic operations it is necessary to handle especially carefully fabrics, avoiding gaps, to-rye can conduct to a circulatory disturbance and a necrosis of fabrics. The section of skin is carried out whenever possible on inborn folds which course often does not match the direction of the standard cuts in surgery based on topografo-anatomic features of access to this or that body. Dissect fabrics are sewed layer-by-layer taking into account their gistogenetichesky origin, an arrangement of skin folds, and at face operations — and mimic muscles. For P. the lake needs a thin suture material with atraumatic needles and the thin not injuring tools.

Plastic surgeries at children make for the purpose of elimination of congenital anomalies and the acquired uglinesses that promotes improvement of growth and development of a children's organism. If defects interfere with normal development of the child, lakes carry out P. at any age, sometimes (as acute management) in the first days of his life. Items of the lake at early children's age undertake, in particular, for recovery of normal suction, (e.g., at not fusion of an upper lip), swallowing (e.g., at not fusion of a hard palate), breath, defecation (e.g., at an atresia of an anus), urinations, etc. If the found defect allows the child to live and to develop well, P. of the lake is postponed until more optimum age period.

Items of the lake at children have the features caused by age factors. Children's fabrics juicy, gentle and thin therefore they are easily broken off and bleed; they are unstable to an infection, especially in the first 5 years of life. Therefore at P. the lake at children needs especially gentle also care with fabrics, thoughtful comparison of a risk degree of operation with risk of the effects caused by weight of ugliness.

Items of the lake at children gained distribution at syndactylias (see), to a hemangioma (see), etc.

Now the plastic surgery at adults and children is improved by means of use microsurgery (see) and autotransplantations.



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P. P. Kovalenko.

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